Gift from the Gila Monster

 

Asterix and Ozempix. When this illustration landed in my SM feed a few months ago it took me a while to figure that the skinny guy next to Asterix was actually Obelix. 

Also just like Obelix, many of my own friends are now becoming unrecognisable, slimmer, trimmer versions of themselves.  One thing they all have in common is that they were all on the heavier side and had all tried various methods of losing weight - gymming, cardio, dieting (keto, med), intermittent fasting - all to no avail. Then came injection pens from brands like Ozempic and Mounjaro...

What is this this oddly named injection the magic cure they seek? From where does this drug originate? What are its long-term side effects? 

Ozempic, Mounjaro, Wegovy, Zepbound, Saxenda, and Retatrutideand, and a host of other brand-names referred to a single chemical compound. These are all called Triple Agonist injections, an advanced class of multi-hormonal medications that simultaneously target three distinct metabolic receptors—GLP-1, GIP, and glucagon (GCG)—originally used to treat conditions like obesity and type 2 diabetes.

Today I finally came across a YT video that seems to present balanced view. 

According to Dr. Amin Hedayat, this drug, branded as Ozempic / Mounjaro was approved by US-FDA way back in 2005, not for weight loss, but for Type-2 Diabetes. Over a period of time, the drug manufactures discovered that this particular drug not only reduced blood sugar levels, hearts and kidneys got healthier, solved sleep apnea and slept better, women suffering from irregular periods got cured..

- How does a single drug solve such a wide range of health problems? In the 1980s three scientists (Abener, Mojsov and Holst) studying a chemical messenger in the stomach - Glucagon-like Peptide-1 (GLP-1). This messenger told the body to release insulin, the hormone that regulates blood sugar level. The original GLP-1 formulation was actually based on a chemical (exendin-4) found in the venom of the Gila Monster (!) because this version lasted longer in the body (why?) compared to the one produced by human bodies.

20 years after being used as a sugar regulator, scientists found that GLP-1 was actually a much more potent messenger. It tells many organs to regulate their own functions, to provide the the body only what it needs needs, not less, not more. The liver was told to regulate sugar output; told the stomach to slow down digestion; sent signals to the hypothalamus to send out signals for satiety - 'don't eat more than this'.

The body's own GLP-1 signals get damped by excessive consumption of ultra-processed foods, chronic inflammation and insulin resistance. So, ultimately, the GLP-1 injection is just a signal booster, effective only as long as your body re-learns to listen to its own signals.

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REFERENCES & LINKS

• Dr. Amin Hedayat - https://youtu.be/RFOrOt-z-Nk
• Gila Monsger - https://www.nhm.ac.uk/discover/the-monster-whose-bite-saves-lives.html

Sikkim - Hypertense Taxpayers?

A few days ago, an old friend, a physician, shared a graph that got me puzzled.

It showed an NHFS-5 graph plotting percentage of men with diabetes and hypertension across Indian states. While he was concerned about Kerala being represented as a large dot far ahead of all the other states on these two ailments, it was a smaller green dot caught my attention - Sikkim.

How did this tiny north-eastern Himalayan state full of people who always seemed so healthy, relaxed and friendly top the charts for hypertension in India? 

Maybe I was being nostalgic about a trek in Sikkim more than a decade ago, of endless bowls of Thukpa washed down with Dansberg beer. That was a business trip to the main hospital in Gangtok, and these lifestyle diseases certainly did not figure prominently then. What had changed over the years? - was this something to do with the diet? 

Another graph presents a different different picture. This one maps a state-wise per-capita collection of the Goods and Services Tax (GST), and the big surprise here is that Sikkim was the leading state with an average contribution of INR32,568 from each of its ~ 600,000 citizens!

Perhaps this is a pointer to the rapid industrialisation that has taken place in Sikkim over the past decades, with all its attendant health problems. Or maybe there is no correlation at all between these two unrelated  indicators.

One thing is for sure - the numbers need to be examined more closely.

Covid Shielded

The lady who helps us with the housework is from a remote coastal village in West Bengal. Yesterday she got a call from her parents and the news was that they were both suffering from fever. A few thousand kilometres away, near the capital city, we too were afflicted by the same symptoms - the expected after-effects of a vaccination national drive against Covid-19. 

We were among the four million+ people who got vaccinated in India today. While the fever and the dull pain of an intramuscular injection abates, it is quite amazing to think of superlative effort that has gone into creating, testing and delivering these vaccines all over the world.

The vaccination program started its rollout in India couple of months ago. First for those over 65 years of age, and for those who were vulnerable due to 'co-morbidities'. At first people were wary, and senior citizens had to be coaxed and cajoled to the vaccination centres. This changed on 1 April 2021 when the government decided to expand the coverage to those over 45 years of age.

The sheer scale of this effort does not hit you until you participate in it. It is a four step process is driven by information technology in which each dose can be traced back to a specific vial at a specific vaccination centre:

(1) Registration at CoWIN site - a single phone can be used to make four bookings at either government 

(2) Selecting a vaccination centre - Based on your postal PIN code you can opt for either the nearest government centres (free of charge) or private hospitals / clinics (fixed at INR 250) 

(3) Vaccination - At the hospitals a queuing system ensures that people maintain social distance. Each vaccine station has three staff  - two for writing out the registration details, one  for preparing the vaccination card, one for checking the CoWIN id, uploading the confirmations online, and a nurse who administers the vaccine. The whole process takes about 8 minutes. After the jabs people are expected to wait for 30 minutes of observation before returning home. 

(4) Certificate - within a few minutes of getting vaccinated an SMS message leads you to an online certificate (PDF) which can be used as proof while travelling.

(4) Follow-up - each vaccinated person is given a card which specifies the vaccine type (Covidshield / Covaxin), the date for the second dose (min. 28 days), emergency helpline numbers and a list of five possible after effects (mild fever, pain and swelling, etc.,)

One thing I have learnt along the way is that the government machinery seems to be far more efficient than the private sector. In my immediate neighbourhood all the hospitals were booked until 14 April, so I expanded the generic Noida PIN code and booked two slots on 1 April at Metro Hospital from a list of about 10 hospitals. 

However my experience at Metro Hospital left me quite disappointed. It is a large hospital in Sector-11 Noida. When I found my way to the entrance the staff seemed paralysed by chaos - there were over a 100 angry, impatient people already crowding inside, with the guards telling the newcomers that they would need to wait for three hours!

I went back to the CoWIN site and got my appointment rescheduled to the  next day at the District Combined Hospital, a government facility in Sector 30. Over here the whole process was a breeze. There was ample parking outside; masks, hand sanitisers and social distancing was compulsory; tokens were being distributed at the main gate and security guards were systematically guiding people through waiting halls while giving priority to the elderly and infirm.

Millions of tiny vials from Oxford-AstraZeneca / Serum Institute of India, Sputnik and J&J have now set out to deal with a virus from China that had the world paralysed for more than a year. Hope is in the air, and in our blood streams.

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LINKS & REFERENCES:

https://www.livemint.com/news/india/covid19-vaccination-over-36-lakh-people-get-the-jab-on-april-1-the-highest-so-far-11617335903675.html

https://www.bbc.com/news/world-asia-india-55748124 - Covishield and Covaxin: What we know about India's Covid-19 vaccines

On the remarkable role being played by Co-WIN and its developers (19 April 2020, Indian Express) - https://indianexpress.com/article/india/co-win-platform-coromnavirus-vaccine-india-modi-govt-7279432/

On Dogs Lovers and Power Illiteracy

Stray dogs protecting their turf (Pic source: DNA 14Dec17)

I have always found it difficult to understand the dynamics and the power of "Noble Intentions". How is it that when two sets of well meaning people, both trying in their own way to create a better society, end up making it more dysfunctonal?

Let me illustrate this with an example: stray dogs in our cities. 

Most people are wary of stray dogs, and see them as a threat, and a health hazard, while there is another set of folks, the 'Dog Lovers' who see nothing wrong in having stray dogs share our roads, parks and public spaces. If anybody gets bitten it is because they 'provoked' the dog, and therefore deserved what they got. 

Does their love for dogs extend to other animals as well? Not quite. Nobody would raise a finger, let alone filing a police case, if a harmless rat snake was beaten to pulp, or if pigs drowned in the sewers. But dogs? They are a 'man's best friend', and therefore, special.

Quite unlike the folks who get bitten on the streets, the Dog Lovers are superbly networked, and well organised. They are loud and vocal; they have the ready attention of not only the local newsreporters but also the sympathies of the Supreme Court. So when they take up cudgels on behalf of the strays, filing police reports against those who are violent towards stray dogs, naming and shaming people, all that the opposition can do is to roll over, and play dead.

How did the Dog Lovers come to weild so much power and influence? Why does our overstretched police force take on the unikely role of protecting stray dogs? The answer is simple: the law requires them to do so. 

As per Indian law, street dogs cannot be beaten, killed or driven away or displaced or dislocated. Under the Animal Birth Control (ABC Dogs) Rules, 2001  enacted under Section 38 of the Indian Prevention of Cruelty to Animals Act 1960 (A Central Act), stray dogs can only be sterilized, vaccinated, and then returned back to their original locations. 

What happens when the state ABC department does not have the capacity (funds, personnel, infrastructure) to deal with an explosion in the population of stray dogs? Nobody seems to know, or care.

In NOIDA along there are an estimated 13,600 stray dogs. A few months ago, a child got severely mauled by a pack of stray dogs . When alarmed citizens got together to drive away strays and ended by beating a stray dog to death, police cases were promptly filed against them. So, at present, the very thought of messing with the Indian legal system, with its backlog of cases, is enough to deter any sensible citizen from messing with stray dogs. It is better to get bitten than to get stuck in the Indian courts.

How did a small band of Dog Lovers manage have such a disproportionate influence on the law of the land? A part of the answer lies in what has been articulated so well in Eric Liu's TED Talk - "Why Ordinary People Need to Understand Power". 

Liu rightly points out that power illiteracy all pervasive and that citizens have depressingly low levels of civic knowledge, civic engagement, participation, and awareness. They are naive about all the forms of power that are at play: money, people, ideas, information, misinformation, the threat of force, the force of norms.

Those few who do understand how power operates in civic life, those who understand how a bill becomes a law, how a friendship becomes a subsidy, or how a bias becomes a policy, or how a slogan becomes a movement, the people who understand those things wield disproportionate influence.

Clearly, Dog Lovers in India belong to the power literate elite who weild a disproportionate influence in our cities. In many ways they themselves are like the proverbial dog in the manger - they will not ease the burden on state ABC departments, nor will they stop barking at those who act against stray dogs.

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BTW

Kerala, seems to be among the few states where stray dogs do not enjoy a special status. It has citizens groups that actively participate in anti-stray dog campaigns and support the culling of strays. Across India, only the High Courts of Kerala and Karnataka have taken the position that local municipal laws prevail over the PCA Act. It is not a state of affairs that pleases the stray-dog lovers.

Thanks to this awkward state of semi-rebellion the state sees a lot of parodies centered around the helplessness of the civil society. In this one, a local alpha stray-dog, "Tiger Sabu" is being interviewed by a nervous TV news anchor, a few days after demonetization: 



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REFERENCES & LINKS

* Jaagruti - Indian street dogs and their rights - https://jaagruti.org/information-to-empower-you/indian-street-dogs-and-their-rights/
* Noida - child mauled by stray dogs - https://timesofindia.indiatimes.com/city/noida/child-mauled-by-stray-dogs-in-greater-noida/articleshow/59198467.cms
* Animal Welfare Board of India - https://awbi.org/
* (4 Jan 2018) Hindu: Stray dog victim still in ICU - http://www.thehindu.com/news/cities/Delhi/stray-dog-attack-victim-still-in-icu/article22362867.ece
* (1 Apr 2018) ToI: Noida: Residents, security guards booked for thrashing stray dog to death- https://timesofindia.indiatimes.com/city/noida/noida-residents-guards-booked-for-thrashing-stray-dog-to-death/articleshow/63565399.cms
* http://www.dnaindia.com/delhi/report-plaints-on-noida-s-stray-dog-menace-fall-on-deaf-ears-2567534
* Eric Liu's TED Talk - "Why Ordinary People Need to Understand Power" -  https://www.ted.com/talks/eric_liu_why_ordinary_people_need_to_understand_power

The Air We Breathe

Over the past one week, I have been analyzing the market for air purifiers in the NCR Delhi region. It is just the right time of the year for an assignment like this - the quality of air here takes a nosedive with the onset of winter.

Today the reports of suspended particulate matter - especially PM 2.5 - were particularly alarming. It peaked at over 715 mg/m3 when the prescribed limit is below 60 mg/m3!

Just before the festival of lights, Diwali, farmers in Northern India harvest their summer crops and prepare their fields for the winter sowing season. Since it is too expensive to physically remove the post harvest residue from the fields they just burn it.  A huge cloud of smoke then slowly drifts over Delhi and settles down with all the smoke from Diwali firecrackers, turning the national capital into a gas chamber.

This year, a one-off intervention by the Supreme Court resulted in a ban on the sale of firecrackers, so there was a marginal reduction in the smog and haze, but it still left most of us teary eyed, and with a niggling irritation in the throat.

Pollution is not bad news for everybody. There has been a spike in the number of companies selling air purifiers, big advertisements in the newspapers point to the fact that 15 odd companies are all set to make hay while the sun shines dimly through the smog.

According to the Philips salesman at GIP Mall in Noida, air purifiers have been flying off the shelves as Diwali gifts. The company is barely able to keep pace with the demand. From what one could see, in their enthusiasm to sell, their glib sales pitch is also barely in touch with scientific facts.

"We human being consume about four kilograms of food everyday", said the Philips salesman, "But do we know that we also breathe in about 24 kgs of air, with all the pollutants in Delhi?" I did not know that. Having been under the impression that the volume of air is measured in liters or cubic feet or cubic meters, I have been trying to figure out the actual volume of air consumed by us everyday.

The World Health Organisation and US-EPA has some clear figures on this. Considering the fact that the air contains 20-23% of oxygen, and that an average human being breathes in about 0.5 liters of air with each inhalation. At about 20 inhalations per minute, we are consuming no less than 6-8 liters of air while we are sitting around doing nothing. This jumps up to 60 liters/minute while running at 5 miles/hour. So it turns out that we are breathing in no less than 14,400 liters of air every day (0.5 * 20 * 60 * 24). This volume would take up all the space in a room measuring about 500 cubic feet!

The Philips salesman might have been talking through his hat, but there is no denying the fact that most of us are unaware of the sheer volume of contaminated air entering our lungs every day!

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LINKS and REFERENCES

*  WHO  Factsheet - Ambient air quality and health - http://www.who.int/mediacentre/factsheets/fs313/en/

* USA - California Env Protection Agency research - https://www.arb.ca.gov/research/resnotes/notes/94-11.htm

* YouTube video - How much oxygen does a person consume/day? - https://www.youtube.com/watch?v=t-QYVKYKyfg

* https://www.quora.com/How-much-volume-do-we-inhale-and-exhale-in-a-day

* Oxygen intake - https://health.howstuffworks.com/human-body/systems/respiratory/question98.htm

That Thingy On Your Wrist

I used to always wonder: Why would anybody want to keep a tab on the number of steps they take each day?

Perhaps this was a notion conditioned during the formative years. I had an grand-uncle who had a disdain for things that were superfluous. Having spent his best years in the Royal Indian Air Force, serving forward bases that were battling the Japanese in Burma during WW2, he always felt that giving precedence to form over function was just "bloody bullshit!". Once while were deep into a conversation, my watch gave off its little hourly beep. He stopped mid sentence, took a closer look at all digital numbers on the wristwatch and asked, "Does the damn thing also tell you the time?"

Soon after this, my Timex died on me and I got a Swatch Chronograph - a chunky metal time piece with dials within dials. I never really understood how to use them all but a chunky watched seemed cool anyway.

Then came the Casio G-Shock. It was certainly not be the most elegant or comfortable thing to wear but it is certainly tough. It can see you through through random rainstorms; the Delhi summer means nothing to its straps; it can be a handy alarm to remind you that your lunch is on the stove; you don't have to set it aside while travelling across time-zones or while diving into a swimming pool.

A slight change of heart came after I watched a TED video recently. An elderly speaker observed that these days, watches are things that are worn by an older, less tech-savvy generation. He gave the example of his daughter who found them distinctly uncool because, "For God's sake, Dad, who wants to wear single function devices?!?"

Now that was a valid point. Surely a piece of equipment you carried on your wrist all day ought to do more than just tell you the time and date? While I was still debating the pros and cons of investing in a health-band it appeared at the door wrapped in a courier from Amazon - a thoughtful Rakhi gift.

I have been using the GQii for two weeks now and I like it. For one thing it is nice and lightweight, then it tells you the time only when you want to know, and despite the fact that its inaccurate, once you start wearing the band it does prod you to pay more attention to physical activity, sleep-timings and calorie-burning.

So now I have revised my notions of an ideal watch. It ought to combine the lightness and multi-functionality of a health-band, and yet be tough enough to be worn just about anywhere. Will there be an affordable product that can, one day, combines the ruggedness of a G-Shock to the multi-functionality of a GQii?

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LINKS

- GOQii leads Wearables Mkt in India - http://indiatoday.intoday.in/technology/story/goqii-leads-indias-wearable-market-xiaomi-slips-to-second/1/757668.html

Delhi Metro: The Odds of Being Intolerant

It has been a while since we saw our celebrities wielding the broom. What has become of the “Swachh Bharat Abhyaan” launched with much fanfare last year? 

Despite all the sporadic campaigns, many of us continues to cringe when we see children toss empty chips packets out of school buses; car drivers deftly opening the door of a moving car, to spit paan on the roads; shopkeepers tossing their garbage right on to the streets, and people nonchalantly walking past piles of litter on the streets. In our feudal mindscape it is still somebody else’s job to clean up after we have had our fun.

Delhi Metro has been struggling with the similar attitudes for more than a decade now. It has been successful, to a certain extent, in persuading commuters to stand in lines while waiting on platforms - especially at large intersections like Rajiv Chowk and Mandi House. Inside the trains, while it has now become rare to find men occupying seats reserved for ladies, and yet, a lot of people do get away with littering, sitting on the floors (especially in-between coaches), and consuming food & drinks on the trains.

I had an experience last week that illustrates something that had escaped my notice – the dynamics of behaviour change in our public spaces. 

On an “Odd-Even” day and I was returning home on the Violet Line of Delhi Metro. At Khan Market, a young couple entered the compartment, their arms overflowing with eatables - two cans of cola, and packets of chips and biscuits. The man got a ladies seat vacated for his friend, and both continues chomping and drinking as the train moved on.

Eating and drinking is prohibited on Delhi Metro. Having seen numerous instances of spilled drinks and discarded food on the trains, I ventured towards the man, apologised for intruding, and quietly requested him to avoid eating on the crowded train and to put away the drinks until he was out of the station.

"Sorry, can't help it", he said loudly, "we are very hungry."

Duly rebuffed, and not wanting to make a scene, I backed off. A few minutes later there was a huge commotion. The fact that a polite request had no effect on the couple seems to have rankled a lot of nerves. A number of passengers had now taken on the couple, and their tone had swiftly moved from polite requests, to expressions of derision, disdain, and anger.

 Now the shoe was on the other foot. Left with no choices, the drinks and food packets were quietly tucked away, and tempers started to cool down.

As I stood there marvelling at the way in which a tired, disinterested group of commuters had suddenly rallied together to keep a coach clean, it suddenly dawned on me that in a city were littering is so commonplace, we often overlook the remarkable fact that that a vast majority of passengers on Delhi Metro do follow the rules. 

In general, there is also an amazing level of toleration for those who break the rules -- until a trigger makes people explode in rage. The incident also reminded me that there is very little visible effort from DMRC when it comes to enforcement of rules and regulations. Never once in the past ten years have I seen anybody getting fined for breaking the rules.

In countries like Japan, eating and drinking is permitted on the metro trains. These are societies that value virtues of tidiness, self-control, and care for the others, a value system is hardwired into children from a very early age. As children turn into adults, it is not surprising to see that they need very little external enforcement of rules. A stage is reached when people not only regulate themselves but also take on the onus of gently reminding others to do so. 

 

It is time we become more intolerant about the litter and garbage outside our own homes.

Tech Transfer - the Aravind Way

Aravind Eye Hospital is undoubtedly one of the most unusual institutions in India. Consider these facts:

• Aravind's surgeons average about 2,000 operations a year. The average for eye surgeons in the U.S. is 125;
• Each year, Aravind Eye Care System conducts over 300,000 sight-restoring eye surgeries — and about half, are free;
• Efficiency brings down the costs but not the quality. Aravind surgeons have just half the number of complications that the British health system has for the same procedure;
• Aravind's JV with David Green resulted in Aurolabs, in 1992. Today, it is one of the largest manufacturers of intraocular lenses in the world, with sales in eighty-six countries. The average selling price of Aurolab's lenses is currently $8 compared to $150 in the U.S. 

How did a not-for-profit Indian organisation like Aravind manage to collaborate with an American entrepreneur, to mass-produce sophisticated surgical devices, at affordable prices?

A good part of the answer to this question lies in the networks & institutions set up by one individual -- Larry Brilliant.

True to his name, this American hippy turned physician, epidemiologist, technologist & author, has been tackling some of the worst medical problems affecting the poor -- smallpox, curable blindness and hearing disabilities. Brilliant teamed up with Ram Dass (formerly Richard Alpert) and Waly Gavy (all devotees of Neem Kakoli Baba), to establish Seva Foundation in 1978.

Seva Foundation tied up with a retired government doctor in Tamil Nadu, named Dr. Govindappa Venkataswamy (Dr.V), and brought in the serial entrepreneur, David Green, to tackle a major bottleneck: making affordable intra-ocular lenses.

These lenses were prohibitively expensive at $100 a piece. Green obtained the technology from an American company for a one-time fee for technology transfer, and then went on to start production in 1992. It has supplied more than 6 million lenses to non-profit users in India and eighty-eight other countries. Today, these lenses cost just $4 a piece (Rs.270).

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LINKS / REFERENCES:

* http://www.aravind.org/ --- Dr. V - http://en.wikipedia.org/wiki/Govindappa_Venkataswamy
* T. Ravilla: developer of the LAICO-Aravind Eye Hospital Care System -- http://en.wikipedia.org/wiki/Thulasiraj_Ravilla -
* Attacking the Backlog of India's Curable Blind -- The Aravind Eye Hospital Model -- G. Natchiar, MD; Alan L. Robin, MD; Ravilla D. Thulasiraj, MBA; Senthil Krishnaswamy, MD -- http://archopht.jamanetwork.com/article.aspx?articleid=640769
* Aurolab India - http://www.aurolab.com/intraocularlenses.asp
* Ydstie, John (2011): India Eye Care Center Finds Middle Way To Capitalism, NPR, November 29, 2011; url - http://www.npr.org/2011/11/29/142526263/india-eye-care-center-finds-middle-way-to-capitalism/
* SEVA Foundation - http://www.seva.org/site/PageServer
* Larry Brilliant - http://en.wikipedia.org/wiki/Larry_Brilliant
* Neem Karoli Baba - http://en.wikipedia.org/wiki/Neem_Karoli_Baba
* Ram Dass - http://en.wikipedia.org/wiki/Ram_Dass
* Wavy Gravy - http://en.wikipedia.org/wiki/Wavy_Gravy

* http://infinitevisionaries.com/blog/